Welcome to my blog. HIV prevalence is not a reliable indicator of sexual behavior because the virus is also transmitted through unsafe healthcare, unsafe cosmetic practices and various traditional practices. This is why many HIV interventions, most of which concentrate entirely on sexual behavior, have been so unsuccessful.

Clearly, three of the top institutions involved in health and HIV in developing countries demand a better reason to investigate safety in health and cosmetic facilities, where skin-piercing procedures may be transmitting HIV and other blood-borne diseases. The reuse of unsterile injecting and other equipment has been identified as a risk factor on many occasions, without this resulting in African people being warned about the non-sexual risks they and their children face. The status quo has been to claim that health facilities are safe and that almost all HIV transmission is a result of 'unsafe' heterosexual sex.

The above esteemed personages, apparently, "recognize that unsafe injections, skin piercing, blood transfusions and surgical procedures can contribute to HIV transmission". However, their currently available data, and even their data collection instruments, are designed to diminish the possible contribution of non-sexually transmitted HIV to the most serious epidemics in the world. So they do, as they claim, make 'explicit reference' to non-sexual transmission, but they expect us to believe that it only accounts for a very small proportion of all transmission, about 2.5% for a country such as Kenya.

The above institutions are much more comfortable with articles such as this: "Tanzania: Unsafe Sex Rampant - Study". The article gives a few snippets from the Demographic and Health Survey, which will probably not be made available to the public in full until the data is at least a couple of years old. But we don't get anything to compare it with, so we don't know how serious it is. We can expect 'unsafe sex' to be 'rampant' among sex workers, but we don't know why so many Tanzanian sex workers are infected with HIV when sex workers from other countries are hardly ever infected unless they have other risks, such as intravenous drug use. And there are many people who are not sex workers, yet they seem to face even higher HIV risks, something WHO, UNAIDS and the World Bank are happy to explain away as 'unsafe sex', without bothering about evidence.

Changing the story from 'there is no problem' to 'the problem is very small' is not a real change. WHO, UNAIDS and the World Bank are still refusing to address the real reasons for exceptionally high rates of HIV transmission in some parts of some countries in Africa, putting it all down to unsafe sexual behavior. But sexual behavior does not now, and has never correlated with HIV prevalence figures. Non-sexual risks have not been properly assessed in high prevalence countries, as if the whole issue is too embarrassing for the HIV industry. But these institutions have failed to have any impact on HIV transmission; what could be more embarrassing than that?

We commend your organizations’ efforts to treat people infected with HIV and to prevent mother-to-child HIV transmission. Such efforts should be continued and expanded. Unfortunately, that will not be enough to stop almost two million Africans from contracting HIV each year.

This letter is spurred by results released in September 2012 from a national survey in Uganda in 2011. We call your attention to one of the findings: 16% of HIV infected children age 0-5 years had HIV-negative mothers, among children with tested mothers. This is the 4th national survey in Africa to match the HIV status of children and mothers. In the three previous surveys, Uganda in 2004-05, Swaziland in 2006-07, and Mozambique in 2009, 16%-31% of HIV-positive children had HIV-negative mothers (see survey reports and analyses of raw data for Mozambique and Swaziland).

To help stop HIV transmission through skin-piercing procedures in health care and cosmetic services, we urge your organizations to tell the African public what UNAIDS and WHO already tell UN, including World Bank, employees: “unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections” (p. 9 here), and “avoid having injections unless they are absolutely necessary… Avoid tattooing and ear piercing. Avoid any procedures that pierce the skin, such as acupuncture and dental work, unless they are genuinely necessary. Before submitting to any treatment that may give an entry point to HIV, ask whether the instruments to be used have been properly sterilized” (p. 23 here).

Warning the public about blood-borne risks for HIV not only allows people to avoid risks, but also empowers and motivates the public to hold their health caretakers (both formal and informal), providers of cosmetic procedures, and ministries of health to a high standard of safety.

Available evidence suggests that warning people about blood-borne risks could have a significant impact on HIV epidemics. During 2003-07, national surveys in 16 African countries asked people how to prevent HIV. In countries where more people said that avoiding contaminated instruments such as razor blades was a way to prevent HIV infection, people were less likely to be infected (see Figure).

Source: For each country, the percent of adults who say “avoid sharing razors/blades” is the average of percents for men and women from 16 surveys, excluding adults who were not aware of HIV or had been previously tested for HIV, as reported in: J Infect Dev Ctries 2011; 5: 182-198. Percents of adults with HIV (except for DRC and Ethiopia) are for 2009 from: UNAIDS, Report on the Global Epidemic 2010; for DRC and Ethiopia these are for 2007 and 2005, respectively, from national surveys available here.

The World Medical Association’s Declaration of Lisbon on the Rights of the Patient avers that each patient has “the right to the information necessary to make his/her decisions.” We ask you to ensure that your organizations adhere to this principle by emphasizing blood-borne risks in HIV prevention education and by making safety a priority in all programming with health care and cosmetic service providers and institutions.

Thank you for the open letter sent to Mr Sidibe, Dr Chan and Dr Kim on 15 October, 2012. We recognize that unsafe injections, skin piercing, blood transfusions and surgical procedures can contribute to HIV transmission, and advise countries that an effective HIV response should take into account all available data on modes of transmission in the design and implementation of their response.

As part of our commitment to reducing HIV incidence and new HIV infections, both the World Health Organization (WHO) and UNAIDS have produced guidance with unsafe skin-piercing procedures. UNAIDS Prevention Policy Paper, and the WHO Global Health Sector Strategy on HIV/AIDS, 2011-2015 make explicit reference to the importance of preventing unsafe injections, surgical practices and blood transfusions. WHO and UNAIDS advise countries to scale up proven and cost-effective strategies, policies and programmes that are tailored to their actual HIV epidemic and its social, economic and health system context (Know Your Epidemic/Know Your Response).

Recently, WHO's Director-General, Dr Margaret Chan called for action on injection safety. Since this call, a cross-departmental working group has been created to develop a policy document and implementation plan on the safety of all therapeutic injections.

Thank you for raising these issues in the letter and for your efforts in the fight against HIV.

Friday, October 19, 2012

I think it was around six years ago that I started to look for something to concentrate on for my Master's degree and I considered choosing something other than HIV. It would have been better if I had done so, because to disagree with mainstream views of HIV is to ensure that you are unlikely to work in the field. But I was distracted by a paper by Eileen Stillwaggon on the roles of co-factors in HIV transmission, such as intestinal parasites, malaria, malnutrition and the like. This was one of the best argued papers I had come across on why we should not view HIV as being entirely a matter of sexual behavior.

Such papers still come out every now and again, and it cheers me to think that one day, people (and by 'people', I mean Africans) may not be blamed for getting infected with HIV through their own stupidity, and as a result of their promiscuity. Epidemiologists may conclude from what they already know, that no disease is entirely independent of lots of other diseases, that HIV may actually be like other diseases in that respect. They may start to believe Africans when they say they have not engaged in 'unsafe' sex, and take a look at other possible co-factors. Perhaps they will even look at non-sexually transmitted HIV and conclude with something more credible than peremptory dismissal.

While FUS is more common in girls and younger women who are not necessarily sexually active, many still have FUS when they become sexually active. Once they are above school-going age they are no longer targets of school-based treatment programs, but this is the time many are becoming sexually active. Women should be treated for this debilitating condition as it can have serious long term consequences. But the fact that it may be associated with HIV infection should by now have attracted the attention even of those who still see diseases as being independent of other diseases, and that includes the vast majority of health and HIV donors.

FUS has not yet received the funding it needs, even though the authors estimate that the cost of controlling the disease may be as little as 32 cents per woman. Compare this to the $60 to $120 per man for the voluntary medical male circumcision (VMMC) program that is running in the very places where schistosomiasis and various other diseases are endemic. For some reason, circumcision is very attractive, despite the fact that the association between lack of circumcision and HIV infection is not particularly large. (However, it is impossible to accurately evaluate circumcision as a risk factor for HIV because the randomized controlled trials used to argue for the VMMC program did not establish how many incident infections during the trial were a result of sexual behavior and how many were a result of some other kind of exposure.)

Attempts at eradicating parasitic and other conditions are not unprecedented. Parker and Allen write about a mass drug administration program that aims to eradicate lymphatic filariasis. But they find that there is a substantial discrepancy between village-level and self-reported surveys of drug uptake, which tend to be low, and official reports of drug uptake, which are high. It is found that many people either don't receive or don't avail of the free drugs, for a variety of reasons. The official figures assure donors that the disease will be eradicated by 2020, which is what they want to hear. But the local figures suggest that eradication will not be possible without some big changes in the way the program is run.

Curiously, the authors remark that "if [parents] reject medication for themselves, then they are likely to reject treatment for their children". I don't doubt that the authors are right, but I have been finding it difficult to understand why most sexually active men in Nyanza,Kenya have been refusing the offer of free circumcision, whereas hundreds of thousands of males in their teens and early twenties have, apparently, been circumcised under the VMMC program. At least one of their parents must have given consent for the younger males to be circumcised.

Parker and Allen note that "context-free, pathogen focused NTD [neglected tropical disease] control is a return to 'magic bullet' medicine, and ignores the fact that vaccines and drugs do not cure neglect or poverty". The same could be said for various HIV interventions, including the VMMC program. They go on to say that "intense competition for funding discourages critical thinking and analysis", which is putting things mildly. Attempts to eradicate various diseases or groups of diseases have a long and unenviable history that includes the history of HIV.

You might think that those responsible for reducing HIV transmission and eliminating various diseases, such as schistosomiasis and lymphatic filariasis, would welcome suggestions as to how they could improve their results. But it seems that some programs report the figures their donors like to hear. If the donors were told the truth they might reduce funding. So there's certainly little to be gained from reporting low and declining uptake and effectiveness. Decades of 'context-free, pathogen focused programs' have shown that it's better to report good news. This is not good news for those suffering from various diseases, nor those at risk of doing so. But, when all else fails, blame the beneficiaries.

Thursday, October 18, 2012

This is the last blog post that draws on findings from my visit to Kenya to interview people about HIV and circumcision. We could go on forever mounting an attack on the Voluntary Medical Male Circumcision (VMMC) program, with those in favor mounting a defense. But my main aim was to hear what people thought about HIV and VMMC, why some were convinced and why some were not. And the most stunning finding for me was how little people seem to question the various programs that are presented to them, whether they relate to HIV, health, education or anything else.

While it could be claimed that most people are convinced that circumcision will reduce HIV transmission, most sexually active men seem to be giving it a miss. They make up the most significant group that would face high HIV risk through sexual behavior. The majority of the hundreds of thousands of people that are claimed to have been circumcised under the program are either in their teens or in their early twenties. But they do not tend to face high HIV risk through sexual behavior.

Another group that seems convinced that VMMC will reduce HIV transmission is women. But they, along with most men I talked to, don't seem to be aware that the 'evidence' from various oft cited trials is about female to male transmission, not male to female. Promoters of VMMC say that transmission from males to females will also be reduced because there will be fewer HIV positive men, but they neglect to mention that far more women than men are infected with HIV, even among circumcising populations. In addition, women seemed convinced that circumcision reduces HIV transmission because being circumcised is more hygienic, yet this is not a finding of any research.

It was shocking to me to find so little doubt about the possible effectiveness of the circumcision program. Sometimes those promoting the program claim that previous HIV prevention interventions have failed or have not worked well enough, even though they need to continue advising people to 'abstain', etc (though this may be a good time to choose more appropriate concepts, ones that people understand). Nobody seems to ask why they should believe that VMMC will work any better than ABC, VCT (Voluntary Testing and Counselling) or various other efforts, or why previous efforts that had so little impact are still being promoted.

Those working on the program are clearly far less convinced about the potential effectiveness of VMMC, though they can be quite defensive. They can cite the various 'advantages' of circumcision, but without the almost religious conviction of people who are not so well educated. But ultimately, they seem to be doing it because they get paid to do so and because they can. It's as if they would immediately get behind a campaign for anything else, should the money be forthcoming.

Sexual behavior change and instances of behavior change were frequently mentioned as ways of avoiding HIV in conjunction with VMMC, particularly condom use. It is clear to people that VMMC on its own is not enough. The head of a clinic that performs circumcisions conceded that behavior change and appropriate advice about genital hygiene may be enough, without circumcision, except for the fact that people do not generally use condoms. But no one questioned the continued need for behavior change if they agreed to be circumcised, nor did they question the need to be circumcised if they did not engage in unsafe sexual behavior.

Several people said they believed HIV was related to poverty, but they didn't ask why poverty reduction was not one of the aims of the VMMC program (or any other large scale HIV program), and only one talked of the need for economic interventions. Those who thought circumcision was 'hygienic' did not ask if access to clean water and adequate sanitation would soon follow, as circumcision without the means for washing would still be completely useless if it was just a matter of hygiene. Similarly, a few associated HIV infection with 'idleness' and several more said it was a matter of unemployment or even boredom. But none asked if creation of employment opportunities was not at least as important as what may only be a slight reduction in HIV transmission.

Although one of the VMMC documents claims that up to one infection could be averted for every 15 circumcisions carried out, the figure during the trials was probably closer to 1/75, so at the community level it's likely to be a lot less effective. But very few raised the issue of methods for HIV positive people to avoid transmitting HIV, even though the VMMC program also circumcises people who are positive and people who don't wish to know their status. We don't have a figure for how many circumcised HIV positive people might result in one or more transmission.

Many people talked about condoms though, perhaps because they were so intent on discussing HIV, they didn't mention their effectiveness in preventing transmission of STIs; only one mentioned condoms as a means of reducing unwanted pregnancy. Perhaps people assumed that the failure of condom promotion programs so far to reduce transmission much is because many people still don't use them, but they didn't raise the question of why people would use them more just because they have been circumcised, or why they should bother being circumcised if condoms work so well.

An interesting question may also be why this campaign seems to be entirely funded by the US, with mostly Americans and American paid people doing the research and implementing the program at all levels. Is there something about American culture that allows such a program to go ahead, with enough public support; or at least, without much effective opposition? One might ask the same question about the ABC (Abstinence, Be faithful, use Condoms) campaign, particularly the version that emphasized abstinence for all, faithfulness for those in a long-term relationship and condoms, but only for those in discordant relationships (where one partner is HIV positive and the other is not).

Both VMMC and ABC sometimes attract similar criticism; for example, would this sort of campaign be carried out in the US and would it work? Circumcision is still quite common in the US among sexually active men, but HIV prevalence is higher than anywhere else in the Western world. ABC (or whatever version they used in the US) failed completely, for HIV, unwanted pregnancy and sexually transmitted infections, which are far less common in many European countries where campaigns resembling ABC or VMMC campaigns have never been considered. Only one person questioned the right of another country to impose this kind of intervention on Kenyans.

My impression is not that the VMMC campaign has failed to persuade people that they should get circumcised. Sadly, I suspect that even a lot of the people who are not lining up to be circumcised think that it really does reduce HIV transmission, they just don't fancy it for themselves. But a lot of parents appear to be giving their consent for their teenagers to be circumcised, so they must have been convinced, whether by the campaign or by their teenagers. But the lack of questioning or debate about VMMC is astounding. In this sense, the campaign resembles many of the HIV campaigns that went before.

Most of the people I spoke to live in terrible conditions and they never asked why circumcision should take priority over decent and safe housing and communities, water and sanitation, accessible and safe healthcare, good education, employment opportunities, infrastructure, facilities for disabled people, and all sorts of other things that are crying out to be addressed. I can not conclude that because people didn't mention any of these that they are therefore not important. But I wonder if what is left unsaid about HIV, circumcision, sexual behavior, health and the rest might also be a lot more important than what is said.

Wednesday, October 17, 2012

Much of the HIV related work that has taken place in African countries over the last couple of decades has concentrated almost entirely on sexually transmitted HIV. There were probably measures taken in the 80s and perhaps even in the 90s to reduce transmission through unsafe healthcare and other routes of infection. But these have been discussed less and less, to the point where it is now generally stated that almost all HIV transmission in African countries (but not elsewhere) is a result of unsafe heterosexual sex.

You may think that this bias towards sexual transmission has resulted in significant falls in incidence (yearly rate of new infections) in countries that have received the bulk of HIV funding. But you'd be disappointed. Uganda has always had a special place in the HIV literature because, whatever happened there in the 80s, HIV prevalence dropped and stayed relatively low since some time in the 90s. But in the last six years (specifically, from 2004-05 to 2011) the percent of Ugandan adults with HIV increased from 6.4% to 7.3%. But the increase in the number of infections is much more, because Uganda’s population increased by 24% over that period. Taking into account more people, of which a higher percent are infected, the number of HIV infections in Uganda increased 40% over those 6 years. Uganda is no longer a success story.

In contrast, Burkina Faso is a country where HIV interventions have not been nearly so well reported and celebrated in the international press. Yet the percent of adults with HIV in Burkina Faso fell by almost half over the last 7 years, from 1.8% to 1%. During this period, taking into account population growth, the number of HIV infections dropped by 37%. Another country where prevalence (the percent of adults infected) has dropped in the last 5 years is Zimbabwe, during which time many aid agencies and donors suspended their work in the country. Prevalence has remained stable but very high in Lesotho and Zambia, but it has increased in Ethiopia. Although the percent of adults infected remained stable in Rwanda, the number infected increased with population growth. [The last two paragraphs have been amended as an earlier version contained several errors.]

So could there possibly be something wrong with the behavioral paradigm, the view that almost all HIV is sexually transmitted? This is not to suggest that HIV is never transmitted sexually, but just to raise the question of how much is transmitted sexually and how much is transmitted in other ways, such as through unsafe healthcare and cosmetic practices. These are not popular questions to raise, but they should be raised now that the orthodox view seems to have such little impact on the epidemics on which so much effort and money have been spent.

People I spoke to in Western and Nyanza provinces in Kenya, and most other people I've spoken to, have assured me that HIV is almost always transmitted sexually. They do, when pushed a bit, mention other modes of transmission, but they don't believe these are particularly important. Some will even tell you about how most people have lots of sex with different people all the time, not usually the person you ask, but other people, naturally. Sex is said to be generally unprotected, involving multiple partnerships, and even concurrent partners. There is also said to be a lot of alcohol abuse, which is seen as inevitably leading to sex and HIV transmission.

It is hard to get people off the subject of sex, the sex lives or others, of course. Even some people working for HIV NGOs realize that not all HIV is sexually transmitted, but they haven't time to research the issue and they will not do so unless there is funding available. There is good money in just accepting the behavioral paradigm. Others dismiss non-sexual transmission and say that it has been shown to be insignificant. I met one person who asked how UNAIDS and the HIV industry could believe that most people had the time, opportunity or inclination to have lots of sex with lots of different people and concluded that they had not actually checked, but such insights are rare.

When persuaded to name modes of transmission other than sex and related activities, some people mentioned unsafe healthcare. Some, independently of the issue of unsafe healthcare, said it was not possible to question anything in healthcare facilities, that the people working in them were secretive. But most people referred to such phenomena as if they didn't think they occurred much. One referred to 'negligent' doctors or quacks reusing sterile needles and others talked of 'village' or 'community' doctors (who are often not doctors at all). A traditional birth attendant said that they often don't have enough sterile supplies themselves, and also that some hospitals, such as village hospitals and dispensaries, are not safe.

Few people mentioned that HIV can be transmitted through unsafe cosmetic practices, such as hairdressers, where razors and other skin piercing instruments may be reused without adequate sterilization. One person had even been warned about such a risk at the voluntary counselling and testing clinic (VCT) where he was tested for HIV. However, he lived on the street, neither unsafe healthcare nor unsafe cosmetic practices are likely to the the biggest risks he faces on a day to day basis.

One difference between sexual and non-sexual risks is that the latter are ones that most people would not wish to take, if they knew about them. If sex is risky, that may not be such a disincentive to some people. If they prefer unprotected sex to using a condom they are unlikely to take much notice of advice to use condoms. But it doesn't seem believable that anyone would prefer to receive an injection from a reused, unsterilized needle. It is unlikely that parents would happily see their children having their heads shaved with a razor that had been used on several others, without any sterilization afterwards.

So what about the current Voluntary Medical Male Circumcision program (VMMC)? Is it safe? Healthcare facilities in Kenya are not safe, research has shown this, without any resulting action to improve safety. Research carried out before the VMMC program started made it quite clear that circumcision in health facilities was very unsafe and circumcision carried out in traditional settings was even worse. But rather than improve conditions in health facilities, a parallel health structure was set up with the sole aim of performing circumcisions. The tens of millions of dollars so long denied to health services was made available to a program that does nothing but circumcise men.

Like many parallel or vertical health programs, a lot of effort went into producing publicity materials claiming that VMMC was not just about HIV, and that it was not only beneficial to men. But this was similar to the research produced to show that such a multibillion program is worthwhile: very unconvincing. Of course, not so much convincing is needed now they have their money. VMMC clinics are probably safe. It's just that other types of health facility are at least as unsafe as they were before. Some probably have fewer trained healthcare workers and some are spending a lot more time on circumcisions, which are never urgent, but are very lucrative.

HIV continues to be treated as if it is in some way different from other diseases, with the result that people can continue to suffer from other diseases, often easily prevented or treated, as long as they are subjected to the popular HIV interventions, that almost always target sexual behavior and now include male circumcision. But targeting HIV as if it is exceptional among diseases has, by and large, failed. If that is because HIV is not always sexually transmitted, male circumcision programs will also fail to have much long term impact on transmission rates. It's almost as if reducing HIV transmission is not really a priority of the VMMC and broader HIV industry.

Tuesday, October 16, 2012

This is the fifth post where I summarize another group of findings from my recent visit to Nyanza and Western Provinces in Kenya, asking people about HIV and circumcision. The first, second, third and fourth are all available and the complete findings will also be made available in due course.

HIV is said (by UNAIDS, WHO and various other institutions) to be almost always transmitted sexually in African countries. Therefore, in the highest prevalence parts of African countries, it must be wondered what kind of sex explains such very high rates. For example, in parts of Kenya rates are very low, such as Northeastern Province. In others, rates are high, such as parts of Nyanza and Nairobi. Among the Luo population of Nyanza, HIV prevalence is was said to stand at 20.2% in the 2008 Demographic and Health Survey (DHS), compared to 6.3% in Kenya as a whole (and even lower among the Kisii and Kuria tribes of Nyanza. But Luos don't appear to have any idea why HIV prevalence should be so high among their tribe, compared to other tribes.

A common suggestion is promiscuity. The DHS does find that some 'unsafe' sex indicators are higher for Luos, but some are lower. And overall, Luo sexual behavior does not seem to explain such inordinately high HIV rates. Yet the head of a clinic that carries out circumcisions simply listed promiscuity, along with various other factors that are often cited for high prevalence in other countries. He did not suggest that levels of promiscuity are higher among Luos, or that their sexual behavior is in any way more risky. Nor did he explain why HIV prevalence does not correlate very clearly with sexual behavior, in Kenya or in any other country.

One community leader, when told that promiscuity can also be common among non-Luos (and non-Africans) without HIV prevalence being high, said that Luos have more sex, do not practice circumcision and do not use condoms. A former public health researcher does not believe that circumcision is the reason for high HIV prevalence but can offer no explanation as to why rates are so high among Luos. A high school student said that Luos may not all be promiscuous but a lot of poor people, mainly females, have sex in exchange for money. Others talk about promiscuity as a reason for high HIV prevalence in general, not just among Luos.

The issue of widow inheritance comes up several times but no one can say how common the practice is. One woman talked of lots of women losing their husbands and being inherited, another says that widow inheritance is 'very common'. A pastor of the Nomiya Church said that if you inherit you will be infected and pass the virus on, although his church also permits this practice. The pastor also mentioned 'traditions' in passing and said that some people think HIV is caused by ‘chira’, taboo. He said that some practices of traditional medicine may also risk transmitting HIV. But he believes HIV transmission is mostly sexual.

A college student said that some males ‘get involved’ with married women, especially widows who have a lot of money, but he does not mention the practice of widow inheritance. However, a former public health researcher said that widow inheritance is no longer practiced much, except perhaps in remote areas, and is unlikely to be an important factor in HIV transmission. He feels that the same applies to other traditional and tribal practices.

One student suggested that younger females have sex with older males for money, and that this is a result of poverty, but that not many younger males do this. Another student said that Luo teenagers can ‘walk with girls’ (a euphemism, also used by someone who was told to avoid 'women who walk around') and be infected with HIV that way. A religious leader and a traditional Luo leader said that some women have extramarital sex in exchange for money, both adding that it was as a result of poverty. A market trader said that Luo people like ‘raha’ (enjoyment, happiness) and translated this as ‘prostitution’. She said there were high rates of unemployment among young people and a shortage of money, leading to transactional sex.

A man who performs circumcisions remarked that most people in high HIV prevalence areas were very poor and that some may have sex as there is nothing else to do. Perhaps this can be compared to a discussion I attended among HIV peer educators in a rural area of Western Province, who were being taught that idleness leads to HIV transmission because idle people are tempted to engage in unprotected sex. But more commonly, transactional sex was said to be a result of poverty, to which a lot of HIV transmission is attributed.

The phenomenon of ‘jaboya’ is often cited as a reason for high HIV prevalence among Luos who are involved in the fishing trade. It is said that fishermen require women to sleep with them if they want to get the best fish to sell. A public health researcher mentioned jaboya as a possible reason for high prevalence in some villages but also pointed out that HIV prevalence can be just as high in villages that have little to do with the fishing industry. But a recent report on HIV prevalence by occupation in Uganda found that HIV prevalence is not exceptionally high among fishermen (or transport workers, who have had the collective finger pointed at them since the early days of HIV).

A religious leader also cited the behavior of fishermen, saying that they ‘lured’ women with fish and money and engaged in transactional sex. A market trader, not herself involved in selling fish, said that young ladies like fishermen and that they have sex in exchange for fish. But the issue of jaboya was hyped by the media some years ago and there seems to be very little real research into the phenomenon, with citations all appearing to lead to the one, somewhat questionable, source.

Polygamy is a popular hobby horse in the HIV industry, although much of the evidence suggests that HIV prevalence is often lower in polygamous societies. A teenager from the Kisii tribe said he thought HIV prevalence was higher among Luos than Kisii because the former practiced polygamy and the latter did not. A health researcher suggested this as a possible reason for high HIV prevalence among Luos and a community leader said that HIV can be ‘brought into the house’ (a sort of euphemism) in a polygamous family unit, but this was not just in relation to Luos. She later said that housegirls are often the ones who ‘bring HIV into the house’. Housegirls have been blamed for many things in the past, including HIV, although there is no evidence that prevalence is exceptionally high among this group (despite the fact that their employment and living conditions are often appalling).

There are lots of posited explanations for high HIV prevalence among Luos, but many are the same explanations for high prevalence among other groups. The problem is that 'unsafe' sexual behavior (paid or unpaid) does not always result in high rates of HIV transmission, so why should it do so in some parts of some African countries? Other posited explanations are not exclusive to high HIV prevalence groups, do not appear, under scrutiny, to explain anything, or they are not widespread enough to account for very high rates of transmission.

Voluntary Medical Male Circumcision (VMMC) is being sold to Luos as a viable way of reducing sexual transmission of HIV, though they are being told that almost all transmission is sexual. If HIV transmission is almost always sexual, it needs to be shown why it is so high among some groups and not others, and what kind of sexual behavior, exactly, is involved. Otherwise, the industry may have to carry out some much needed research into non-sexual transmission, at least to rule it out, rather than to continue dogmatically denying it exists, without any evidence whatsoever.

Monday, October 15, 2012

Aside from many people in Nyanza that I spoke to being convinced that circumcision reduces HIV transmission, some also mentioned lack of clarity, information bias and/or lack of information, or showed signs of being confused about the VMMC program (Voluntary Medical Male Circumcision). Some said they were completely influenced by the mainstream view about HIV being almost always transmitted sexually in African countries, and that therefore they believed VMMC could be effective. They agreed that there was room for doubt, but also said that they did not have the scope for questioning the mainstream view and they were aware that many funding sources require a strict adherence to this view.

One person working for the program said he was obliged to find and disseminate positive things about VMMC and ignore or quash negative beliefs. Another, who worked in public health, said he and others in the field had to work on programs that would get funding. VMMC gets a lot of funding, as do many projects that assume that HIV is almost always transmitted through heterosexual sex in African countries. But projects to improve health systems, water and sanitation, nutrition or neglected tropical diseases will not generally get funding, unless they can be shown to relate to HIV transmission in some way. Even programs that have no connection with health, education or the like are often required to show how many HIV positive people benefit or how many ‘AIDS orphans’ will benefit, etc.

Only one person pointed out that circumcision does not appear to protect Americans, yet the funding for VMMC all comes from the US. He feels the program is being forced on Kenyans at all costs and was also aware that HIV prevalence is low in Europe, where circumcision is generally not common.

A traditional Luo leader feels that he and other senior Luos were not given access to all the information available when they were being lobbied to get behind the program, although he was the only respondent to be clearly aware that HIV prevalence is as high among circumcised as uncircumcised Luos. Another traditional Luo leader felt that he and his fellow Luos were not always given clear information and that important issues may not have been addressed, such as the question of why many people in other circumcising populations are HIV positive. He still believes the program can work but also feels that progress needs to be evaluated on an ongoing basis and that adjustments may need to be made over the duration of the intervention.

A senior government officer had given the matter of sexually transmitted HIV a lot of thought and, understanding the connection between circumcision and sexual transmission, did not feel it had ever been explained why HIV prevalence was so high among Luos. He said he didn't think Luo women had 'more sex' than women from other tribes. In contrast, another senior government officer accepted the mainstream view about HIV and fully supports VMMC. A religious leader in Nairobi appeared to know little about HIV, despite working with sex workers, refugees and others thought to be at elevated risk of being infected.

There are several striking examples of gaps and imbalances in the kind of information people appear to have had access to. A local government leader from a circumcising tribe said there are a lot of misconceptions about the sort of protection circumcision gives and that some women think there are no HIV related risks with circumcised men, that they are ‘safe’. A market trader, who believes VMMC will be very effective at reducing HIV transmission, also believes (incorrectly) that HIV prevalence is always lower in areas where circumcision is widely practiced. A pastor I spoke to seemed relatively well informed about HIV, but he had trouble separating information from spiritual guidance. A traditional birth attendant, who has also worked as a community health worker, says she is confused about whether circumcision really reduces HIV transmission and would like to know where the idea comes from. She also says that her clients and community understand little about HIV.

A ‘street kid’ was encouraged to be circumcised by his girlfriend, who believes it ‘prevents’ HIV, but neither seem to realize that it is only thought to reduce transmission from females to males. Although this man was informed about non-sexual as well as sexual risks, he was not aware that circumcision only reduces transmission through sex. Another ‘street kid’ had been persuaded to have the operation and was told that it would be more painful if he waited till he was older, but he was already 15 and the claim that it would be more painful sounds quite dubious. People who are considered to be too sick to be circumcised immediately are supposed to be treated first, and then circumcised later. But it seems that people who live in conditions where circumcision would always involve risks for them are not so lucky.

Many spoke of a need for further research, for example, a former public health worker who does not oppose VMMC but does not think it will work very well. He said the evidence for the effectiveness of circumcision in reducing HIV transmission is not strong and that there has been little research into non-sexual modes of transmission, including unsafe healthcare. Someone involved in the program agreed that evidence is weak but said that it is getting stronger as time goes by and that in scaling up VMMC they are also seeking new evidence. The head of a clinic that performs a lot of circumcisions also said the evidence is not that strong and that the level of protection from circumcision may be lower outside of a randomized controlled trial, but that he does not yet know what level of protection can be expected as they are only four years into a ten year program. However, he also said the decision to concentrate on circumcision and less on any other HIV and health interventions was one taken by donors, not by people working in healthcare.

Several people asserted that what they had been told about VMMC was ‘science’. A religious leader said we should proceed with VMMC because research has shown that it works. A senior government official describes the 60% protection as ‘scientifically proven’. But a senior public health expert working on the program did not emphasize scientific certainty at all, saying that ‘you don’t know until you try it’ and that this is always the way in science and public health. He did emphasize agreement among normative agencies, donors and the great majority of scientists, though. He pointed to the evidence that is being gathered about the effectiveness of VMMC since the program started, rather than the evidence from several randomized controlled trials.

People who refer to ‘scientific’ and ‘official’ findings are often thinking of three randomized controlled trials that purport to show that circumcision reduces sexual HIV transmission. But they are unaware that it was not shown that all incident infections during the trial were sexually transmitted. A number of people seem to think that circumcision reduces HIV transmission per se, although it is only thought to reduce transmission from women to men. No one raised the possibility that the operation may not reduce, and may even increase transmission, from men to women. The potentially dangerous fact that HIV positive people can be circumcised under the program, whether they know their status or not, was not raised except by someone working for the program.

Sometimes the VMMC propaganda machinery is very efficient. People I spoke to do not adhere to the ‘no risk’ myth about circumcision, the belief that once you are circumcised you don’t need to take other precautions. On the contrary, most people mentioned the 60% figure and added that other precautions were still necessary, often without any further questioning. Some do attribute the ‘no risk’ myth to others, however. But whether circumcised or not, many are clear that the effectiveness of VMMC still depends on individual sexual behavior.

Despite this, one man who works in a VMMC clinic does not seem to believe that people will take behavior change related precautions once they are circumcised, especially as behavior change communication does not seem to have had much impact in the past. He believes that VMMC may provide some protection even to those who do not use condoms, and (somewhat inexplicably) that the combining of circumcision with other precautions will work better than they did before VMMC was implemented.

Only two people talked of deliberate transmission of HIV. The first said that HIV positive people did not want to die alone and that they would ‘donate’ their HIV to as many people as possible. She also believes that there are several signs by which one can tell a person is HIV positive. She thinks VMMC will help but that HIV positive people need to be more careful. The second is a traditional birth attendant and she also uses the term ‘donate’, saying that this is sometimes a revenge for being infected. Apparently associating being HIV positive with particular behaviors, she said that HIV positive people drink a lot in bars as they ‘donate’ HIV.

I was surprised to hear a health worker on the VMMC program saying that women on antiretrovirals can be the most desirable in a community as they look so healthy and fat. But a senior government officer said almost the same thing when asked to give her opinion on HIV and circumcision. A mother and housekeeper said that if someone is thin and then receives ARVs, they get fatter and change in other ways too. But she also said that you can tell when someone is infected because they have spots and boils, different skin color and that the part of the face next to the mouth is fatter.

Billions of dollars have been poured into HIV, although transmission rates (incidence) do not seem to have changed much in the last ten years in Kenya (or even Tanzania or Uganda). So people can be expected to be familiar with the HIV flavor of the month, which in Nyanza right now is circumcision (VMMC). Gone are the days when the first thing some would talk about is ABC (Abstain, Be faithful, use Condoms) or even VCT (Voluntary Testing and Counselling). Abstinence was mentioned twice, condoms were mentioned perhaps because they are a focus of the circumcision program, but being faithful was barely mentioned and being tested was only mentioned once. No one used the term 'ABC' at all.

Various elements of the VMMC party line are repeated with almost religious fervor by most people when you ask them about their views on HIV and circumcision. Even Luos repeat the various posited explanations of exceptionally high HIV prevalence in their own tribe, though these explanations are both insulting and unsupported by evidence. Many object that HIV prevalence can also be high in circumcising populations but, despite being given no adequate response to this, an alarming number seem to have given their consent (arguably 'informed' consent) for their teenage boys to be circumcised. It seems that in the HIV industry there is no right and wrong, only funded and unfunded.

If the Wikipedia entry for 'Jaboya' is anything to go by, IRIN is also the main source for that story too: "an economic system common in the fishing towns of Kenya, on Lake Victoria. It is a system where the fishermen in the region form relationships (commonly sexual) with women in the communities who wish to purchase the fish to take to the market to sell. It is not uncommon for both the fishermen and the women to have multiple partners. As a result of the vast web of these relationships, the Jaboya system is said to account for the rampant increase in the HIV prevalence in the region. It has also caused the mortality rate in the region to increase." All 11 references come from IRIN.

So I wasn't surprised to hear about the jaboya system when I went to places near Lake Victoria to ask why so many people there are infected with HIV, a sexually transmitted infection, even though people all over the country have sex, yet prevalence is far lower almost everywhere else. IRIN's film 'Deadly Catch', is cited all over the web, in mainstream and less mainstream media sources. Like the story about eating cow dung, the story of women having sex with fishermen, bus drivers and market traders really captures journalists' 'imagination', a ready-made story about how Africans are easily different enough for a difficult to transmit virus like HIV to infect up to a quarter of adults in some areas around Lake Victoria.

I'm not saying IRIN made up the whole thing, I'm sure at least part of the film is based on something that happens in the area where they made the film. But I think the phenomenon is in need of a bit more research and analysis. For example, how many people, exactly, are involved in this practice? Saying this or that is 'common' doesn't really tell you anything. It is vital to know what other health risks people face, sexual and non-sexual, in order to understand the exact role this phenomenon plays in HIV transmission. Are there other diseases involved, sexually transmitted and otherwise? A brief film is great for grabbing headlines, but short on analysis. It came out seven years ago and has been widely cited, but what do we know about the practice now?

The IRIN correspondent blusters about civil servants: "These people [civil servants] are always in workshops, where they meet and interact with many people. They have little time to spend with their families. This gives them enough time to have 'side dishes' [extra-marital relationships]," said Samuel Lyomoki, a member of parliament representing workers, told IRIN. "They are involved in reckless behaviours. There is a need to sensitize and take services like counselling and voluntary testing to them." I wonder how many of the workshops 'these people' attend are about HIV. Note also the mention of 'side dishes', another term that appeals to journalists.

Another beloved explanation, repeated by many when asked about high HIV prevalence among Luos, is polygamy. Some Luos do practice polygamy but there is no evidence that levels are higher in Luo areas than in other places where HIV prevalence is a lot lower. Why would it result in higher rates in just some areas? And, as the IRIN film notes, some women are 'inherited' by a relative of their husband if he dies. Of course, there is nothing about how common widow inheritance is, just the assertion that it occurs, or is 'common'. Some people will tell you that it is no longer common; but it fits in well with the story about 'traditional' practices, which are 'bad', compared to modern practices expounded by forces of good, such as the UN and it's multitude of agencies and sub-agencies.

Years of this kind of propaganda by IRIN, the UN, the US Center for Disease Control (CDC), the WHO and others means that you will hear exactly what you expect to hear if you ask people. Luos wheel out the usual about promiscuity, lack of condom use and a handful of other phenomena that have been dug out to make HIV prevention more appealing from a publicity point of view. And people have been persuaded to give their consent (arguably 'informed' consent) for their teenagers to be circumcised. Most sexually active people are saying no to circumcision, but those running the program don't really care, they get paid anyway.

Something that comes across clearly in the IRIN film, though it is not a particular focus, is that many people around Lake Victoria live in great poverty, receive very little education, live in appalling housing and dreadful environmental conditions. Health services are minimal, not particularly accessible and the disease burden is very high. There are few employment opportunities and there is little in the way of entertainment. There may be brief references to these circumstances, but the thrust of the film is that people have a lot of unsafe sex a lot of the time with a lot of people.

IRIN know how to put together a tear jerker and the entire film is shamelessly exploitative, both of the respondents and the audience. But analyzing evidence of HIV in terms of what kind of sexual behavior must have caused it, then analyzing evidence of any kind of sexual behavior in terms of what levels of HIV transmission will result, leads to a lot of circular reasoning. IRIN's claims about jaboya may now require some further research (as may their claims about dung-eating Swazis), and they should make more effort to find out why civil servants face such high risks of being infected with HIV, aside from spending a lot of time in workshops.

There are questions to be answered, truthfully this time. It's very likely that we were wrong about fishermen, sex workers, long distance drivers, 'housegirls', teachers, people who live close to Lake Victoria and various other groups who have had the collective finger pointed at them. It seems we were also wrong about civil servants. However, though high HIV prevalence among them could indicate sexual risk, it could also indicate non-sexual risks, such as through unsafe healthcare, to which they have far better access than unemployed people and those in informal employment (the majority).

We have not shown that HIV is always or almost always transmitted sexually, so we can not go from HIV infection to inferring levels of unsafe sex; nor can we go from evidence of unsafe sex to predict that HIV prevalence is high or that it will become high in the near future. We must know that by now, but we still keep on doing it. IRIN is famous for it and if they really want to do research to 'improve' their services, they should have a look back through their own disgraceful record when it comes to honest research and analysis.

Friday, October 12, 2012

The second grouping of data collected in Kenya is about negative perceptions of circumcision, which are currently less numerous than positive perceptions (the subject of yesterday’s post). But one of the most powerful arguments against the voluntary medical male circumcision campaign (VMMC) is that HIV prevalence is also high among circumcising peoples, even among Luo populations. The figures cited by those promoting VMMC are for all Luos, among whom HIV prevalence is high, compared to all non-Luos, among whom HIV prevalence is generally a lot lower. Many Luos are uncircumcised and many non-Luo Kenyans are circumcised. So this is said to be evidence that circumcising hundreds of thousands of Luos, perhaps even millions, will reduce HIV transmission.

The flaw in this argument is that about 20% of Luos are circumcised, for various reasons, including religious, medical and perhaps others. But HIV prevalence is roughly the same among circumcised and uncircumcised Luos. So, even if circumcision protects non-Luos, it doesn't appear to protect Luos. The surprising and disappointing thing is that Luos themselves don't seem aware of this. Some were aware that HIV prevalence can be high among circumcising peoples, but only one seemed to know that HIV prevalence among circumcised Luos is about the same as among uncircumcised Luos. This suggests clearly that the difference in prevalence between Luos and non-Luos probably has little or nothing to do with circumcision status.

I spoke to several people who worked in public health and they knew about the above flaw in the VMMC campaign's arguments, but they should have known also that the evidence currently shows that the operation does not protect Luos. One community leader points out that, though it is US money that is pushing this campaign, many circumcised Americans die of AIDS. It was a traditional Luo leader, a 'Luo elder', who knew that Luos don't seem to be protected by circumcision. But he and other traditional and political leaders agreed to promote the campaign for the good of public health. He and some other elders are now calling for further discussions to clarify these issues.

There is a Christian sect called the Nomiya Church that practices circumcision on 8 day old infants, and any other church member who wishes to be circumcised. One of their pastors told me that only about 40% of members are circumcised. But the church is almost exclusively a Luo church and despite many members being circumcised, HIV prevalence is very high in areas where the Nomiya Church is strongest. The pastor and his bishop agree with this, but they appear to feel that circumcision is more of a spiritual intercession than a public health intervention.

Others I spoke to felt that VMMC would not reduce HIV or would not reduce it much. One community leader advocates against circumcision and he wonders why the US feels it is acceptable to insist that Kenyans and Africans 'need' this intervention, for which they are willing to shell out several billion dollars. He said there were people circumcised under the program who subsequently became infected with HIV. Several public health researchers I spoke to, some who worked for the VMMC campaign, did not even pretend that they thought VMMC would reduce HIV much, if at all. But several of them also pointed out that there was money in VMMC, which means that it will take priority over anything else.

A few people expressed opposition to forcible circumcision, which has been happening on and off for many years. While this is not directly related to VMMC, witnesses to a recent forcible circumcision said the mob involved claimed they were 'kicking AIDS out of Africa'. Some just shrug their shoulders when asked about forcible circumcision, much as they do when asked about other mob activities, such as lynchings for alleged robbery and other offences or assumed offences. Several expressed complete opposition to infant circumcision, but not many. They don't seem to be aware that there are currently trials of infant circumcision in the area. There is no evidence that infant circumcision has any public health benefit relating to HIV, but evidence can always be manufactured.

Only one person spoke of the irreversibility of circumcision in relation to infants; only one spoke of human rights and informed consent; very few mentioned pain. None at all mentioned adverse events, such as infection, scarring, permanent injury, dysfunction, excessive bleeding and the like (although the most alarming evidence of these was collected by the people who are now running the VMMC campaign). Many mentioned 'hygiene', as if uncircumcised men can't clean their penis and as if all circumcised men do clean theirs. But no one mentioned the conditions they lived in: slums, mud houses, piles of smoldering rubbish, stagnant puddles, rotting waste and open defecation, which results in a contaminated water supply which is used for drinking, cooking and cleaning.

Even a 'street kid' who was circumcised under the program, and was still in great pain when I talked to him, didn't ask how he was supposed to keep the wound clean while living on the street, let alone how having a circumcised penis would protect him from the many diseases stemming from inadequate water and sanitation that account for a huge proportion of morbidity and mortality, even among those who are not forced to live on the streets. How someone could persuade him to have an unnecessary and invasive operation, collect him from the street, give him some written instructions and deliver him back on the street again is beyond belief.

Issues of irreversibility, informed choice and human rights are raised in Western countries, such as the US, and rightly so. But circumcision is associated with a very different set of issues in a country like Kenya, where the vast majority of people live in poverty and appalling housing, only have access to unsafe healthcare facilities and receive an atrocious education that often ends far too early in life. It's not that circumcision is killing so many people but that so many preventable illnesses and social problems are killing people and the US has decided that circumcision is what they need. The above conditions are experienced by most Kenyans, circumcised or not, so what will be done once everyone is circumcised? Perhaps Bill Gates (he funds some of the research) will pay someone to invent an antidote to post-circumcision sepsis.

Several of those involved in pushing VMMC have no illusions: it's about money. Some of them admit that they don't believe it is a useful public health intervention. One didn't admit that, but he did say they are still collecting the data and it's looking better and better as time goes by. Meanwhile, all uncircumcised Luo men (and boys and infants) and their sexual partners have become so many million guinea pigs in this big experiment. Religious leaders have come to see HIV as a way of attracting followers, so they are not complaining. Long held cultural prejudices about circumcision making a boy into a man have greatly assisted the program. So the time-honored combination of money, religion and political power is being used to misinform people whom they claim to be supporting, leading and informing.

Thursday, October 11, 2012

I have been writing up my findings about circumcision and HIV from my visit to Western and Nyanza provinces in Kenya so I haven’t had time to concentrate on blogging. But this post will be about a group of findings and subsequent posts will look at other groups. There are seven groups of findings, representing the seven major themes I could identify. Of course, anyone else looking at the same findings might divide things up completely differently, but that’s the way with qualitative findings. In fact, you could say the same about a lot of quantitative findings, but scientists tend not to draw attention to any of the more subjective aspects of their writings.

The most common finding was that most people believe what they have been told, that circumcision reduces HIV transmission. Most follow this by saying that it only gives partial protection and that other precautions need to be taken to reduce the risk of HIV transmission further. The ‘60%’ level of protection was cited far and wide, though no one attempted to redescribe it or explain what exactly it means. But despite at least 20 people expressing the above finding, only four Luos, the main target of the exercise, had been circumcised under the current Voluntary Medical Male Circumcision (VMMC) program; one of them worked for the program and another was a traditional Luo leader, who agreed to be circumcised to help promote the program. A boy who lives on the street and a third level student were the other two. Sexual risks are unlikely to be the worst threat to the health of the former and the latter didn’t seem to face any serious sexual risks.

Six were women, some were from tribes who already circumcise, some had been circumcised for other reasons, often as an infant, for religious reasons. Three were all in favor but were still considering having the operation. One said all the right things about VMMC, as he promotes the program and recruits people to be circumcised. But he then made it clear that he didn’t actually believe any of the rhetoric, he just said it because it was made clear that he would have lost his job otherwise. Another who worked for the program praised VMMC vigorously but when I pressed him about higher health priorities he agreed and said that donors decide what priorities donor money should be spent on.

Another man who worked on the program, an ex-pat, said that the evidence is not strong but it is sufficient, that it is getting stronger, that it could be worse, that some public health programs are supported by weaker evidence, that some vaccines offer a lower level of protection, that you don’t know until you try it, and that that is the way public health and science work. While he may be right, he is one of the most senior public health experts working on the program, this is not the ringing endorsement that VMMC receives in the press or in UNAIDS, WHO or other institutions’ colorful brochures.

The VMMC employee expressing such strong views about donor priorities said he thought it was easier to put on a condom after being circumcised. But the man engaged in promoting VMMC said that for everyone who expressed such subjective views, you could find people who expressed the opposite view. Several women said it was easier to wash a circumcised penis but they conceded that a circumcised man can still fail to wash himself. Surprisingly, with all the talk about hygiene, none of them pointed out that they live in slums, with no running water or proper sanitation. An extreme example was the boy who lived on the street, who was given a lift ‘home’ after the operation and left to look after the wound while living wherever he could find shelter.

A senior health worker working with the VMMC program was willing to concede that appropriate penile hygiene in conjunction with safe sex practices may obviate the need for circumcision but said, on balance, that people just don’t wear condoms. He was not able to suggest why circumcision should promote condom use if behavior change communication interventions had not done so in the past and he agreed that some of his claimed advantages of circumcision did not correspond to findings from randomized controlled trials.

While some said that circumcision can reduce other STIs, none said which ones, or what level of protection could be expected. Some had to be prompted to list other advantages of circumcision and none mentioned that using condoms reduces transmission of STIs, as well as HIV. Only one person mentioned the use of condoms to prevent pregnancy. After years of public health programs about ABC (Abstain, Be faithful, use Condoms), only two people mentioned abstinence and none mentioned being faithful as a means of reducing HIV transmission. ABC itself was not explicitly mentioned.

A couple of people working for NGOs said that they don’t apply for anything they won’t get funding for, and they know that they won’t get funding for HIV interventions that do not target sexual transmission. A senior public health worker said that he could apply for funding to address something like unsafe healthcare, but he knows it would be pointless, that he would not get any money for it. Some don’t believe VMMC will have much impact, others are indifferent to the question of impact, being more interested in funding, faith or politics than mere effectiveness.

Few people publicly question or oppose circumcision, although a few are opposed to infant circumcision and forcible circumcision. Several mention that VMMC received the ‘blessing’ of traditional and political Luo leaders. But even some of them believe that political support may have been a result of political motives, rather than the claimed public health benefits of circumcision. Luo politicians and the Luo electorate are tired of the discrimination against them that is said to stem from the belief held by members of circumcising tribes (the majority of Kenyans) that until one is circumcised, one is a boy, and that an uncircumcised man can not be president.

So you could easily use the above findings to promote circumcision by reporting the bits that make it seem like an effective and popular intervention. That seems to be what those writing the publicity for VMMC do. The claimed 450,000 people who have been circumcised under the program may be true. But how many are not yet sexually active, no longer sexually active, HIV positive, from tribes that already circumcise or already so enthralled by mainstream HIV rhetoric that they would be circumcised anyway, so they are probably not high-risk in the first place? We may one day get answers to those questions. Meanwhile, those who are most at risk are, apparently, staying away in droves.

This is a useful scenario for those working for the program. If most of those being circumcised do not face high risks of being infected with HIV, they will form a low HIV prevalence group, who all happen to have been circumcised. If most of those who face high risks are currently not being circumcised, they will form a high HIV prevalence group, who all happen to be uncircumcised. And if anyone who is circumcised happens to become infected with HIV, they can be accused of engaging in 'unsafe' sexual behavior. Since most sexual behavior can be construed as unsafe in high HIV prevalenc areas, the VMMC program should continue to look like a great success.

Friday, October 5, 2012

A fairly typical headline on AllAfrica.com: Zimbabwe: Investment in Maternal Health Critical. You could put any sub-Saharan African country in the title at any time and you would have a ready-made story. Around the world, one woman dies from complications relating to pregnancy and childbirth every 90 seconds. For Zimbabwe, the figure is about 10 women and girls a day. The "prevailing maternal mortality rate stands at 960 deaths per 100,000 live births, up from 725 deaths per 100,000 in 2009/2010, while child mortality rate is at 86 per 1,000 live [births]."

Zimbabwean Deputy Prime Minister Thokazania Khupe wants to address these issues by scrapping maternity fees at hosptials and clinics and she has sourced $40 million to subsidise the cost. But this is said to be far too little to have much impact on mortality and the scheme has already been suspended.

It may seem daunting to raise sums like $40 million in a hurry, or even higher sums. But it seems Zimbabwe does have a lot of money at its disposal, money which would be far better spent on maternal and child health. Another AllAfrica.com story says that a USAID funded program aims to circumcise two million Zimbabwean men by 2015. As only 55,000 have so far undergone the program, there must be a lot of money left over. Whether you take the ridiculously low price claimed by circumcistion enthusiasts of about $60 a head, or the more realistic $120 a head, that's still a lot of money, between $117 and $233 million.

Why do I think this would be better spent on maternal and child health? Firstly, because HIV prevalence is roughly the same among circumcised and uncircumcised Zimbabweans. In other words, circumcision hasn't made any difference so far, why should it do so in the future, aside from the fact that proponents of mass male circumcision programs really really want it to work? Secondly, circumcision is only claimed to reduce transmission from women to men, not from men to women. The operation may result in increases in transmission from men to women and infections are already far higher among women.

The country has between three and six times the amount of money they need to substantially reduce maternal (and infant) deaths; spending it on a mass male circumcision program will not reduce HIV, and may even increase it. So why the hesitation? Even if UNAIDS insist that they can only spend this money on circumcision, Zimbabwe would be better off saying no to it. They have nothing to lose by asking.

Most of the deaths are easily preventable and the amount of money available is substantial. The amount saved by not increasing HIV transmission may also prove worthwhile. The article continues: "Africa faces a health-worker crisis: on average, there are only 13.8 nursing and midwifery personnel for every 10,000 people. In the poorest countries, this ratio is less than 1 per 100,000 people". Mass male circumcision programs require huge numbers of health personnel to be retrained, and then their time and attention are diverted from all other health issues. Instead of being trained to carry out circumcisions, additional personnel could be trained in maternal and child health, so that everyone, whether rich or poor, urban or rural dwelling, can have access to decent healthcare. Apparently "80 percent of midwifery posts in the public sector are vacant".

This model could be repeated throughout Southern Africa because it is intended to circumcise 20-40 million men, representing between $1,200,000,000 and $2,400,000,000 if the cost is about $60 per head and up to $4,800,000,000 if the cost is a more credible $120 per head. In addition, the net contribution of circumcision to HIV reduction across 15 high and medium prevalence countries is zero. Many infections from males to females may even be averted, releasing even more funds for maternal and child health.

While circumcising between 20 and 40 million men may seem like non-starter, development programs often seem to take a rather oblique approach. In an article about Kenya, 'Boosting contraceptive use to cut unsafe abortions', you might think providing safe abortions would have a more direct impact. Uptake might be higher too, given that there are many reasons for not using contraceptives. Even in countries where abortions are illegal, ensuring that healthcare is safe and accessible could be a far better way of meeting some women's reproductive health needs.

One of the people interviewed in the article says how confused she was about contraception and suggests that those around her were also confused. But some of the biggest and best funded NGOs have been pushing contraception aggressively for decades in African countries. It doesn't yet seem to be apparent to these NGOs that people who have been denied basic education and health for generations are a lot more difficult to provide for.

Vertical health programs, such as the ubiquitous 'family planning' programs, may be well meaning and often well funded, but understanding of complex issues requires at least some basic education. Simplifying the issues may result in people being able to trot out what they have been force fed on cue, which is great for publicity, marketing, monitoring and evaluation purposes, but it doesn't lead to understanding.

One of the most aggressively marketed contraceptive methods is injectible hormonal contraceptives such as Depo Provera. These are not only expensive, but they have been linked to increased HIV infections among women and increased transmission of HIV from women to men. Appropriate and safe reproductive health may cost a lot less than heavily marketed and overpriced commodities. But instead of finding ways of replacing Depo Provera and similar methods with safer methods, which may also mean lower costs, some contraception obsessed NGOs, backed up by the commercially aware WHO, have issued confusing advice, and continue to push something that could be increasing HIV transmission, with the justification that it is very effective at reducing conception.

Several people working on the mass male circumcision program in Kenya told me that they concentrated on circumcision because there was funding for it. If there was funding for other programs, they would apply to implement them too. There was opposition to circumcision when it was first mooted, but those who really really wanted the program to go ahead took steps to reduce that opposition. If it can be done with circumcision, why not abortion? What kind of cultural and religious objections can people have to abortion that they wouldn't also have to underage sex, extra-marital sex, procrastinated rape, rape and other phenomena that may result in attempted and unsafe abortions?

Development priorities may well be, as some say, all about money; but there seems to be a lot of money around. However it needs to be spent on programs that improve people's lives, not ones that provide some benefit that may be more than offset in some other way. If Luo politicians, Luo people and the populations of many other African countries got behind mass male circumcision, why not invite them to choose development programs that are genuine priorities rather than donor obsessions? The same NGOs will have their snouts poised over the trough, it's all money to them. But there are beneficial ways of spending it and most Africans probably know what they are. Western donors clearly don't.

It has also been pointed out to me that new HIV infections in men who were in the control group, and who remained uncircumcised in the years following the randomized controlled trial, increased substantially to 1.93%, compared to 1.3% in uncircumcised men in Rakai at the time of the trial (many in the control group opted to be circumcised after the trial finished). So in addition to not showing how men were infected, whether through heterosexual sex or some other mode of transmission, it remains to be shown why taking part in the trial would have increased risk of HIV infection among those who did not get circumcised.

The "comprehensive package of HIV prevention services" includes "risk-reduction counseling, provision of condoms and instruction in their use, the offer of HIV counseling and testing, and screening and treatment for sexually transmitted infections". These have been made available to those who were circumcised and to those who remained uncircumcised, without being of much benefit, it seems (bear in mind also that many of the recipients of these 'packages' are not sexually active and may not become sexually active until many years later). But they all relate to sexually transmitted HIV, not to any other mode of transmission. Perhaps the continued failure to identify how people are becoming infected with HIV should now be addressed as a matter of urgency.

Rather less reassuringly, an article on the safety of the voluntary medical male circumcision (VMMC) program finds that those carrying out the circumcisions (mainly nurses and clinical officers, not so many doctors) apparently only receive two to three weeks of training and a relatively brief supervision period. Also, while clients are given written instructions on wound care and the "42 day sexual abstinence period", it is not clear what illiterate people receive. Only 39.4% had completed secondary school. It is completely unclear how those who live on the street or in slums, or those who don't have regular access to clean water and hygienic living conditions, the majority of people in Kisumu, are supposed to care for their hygiene needs, either straight after the operation or in the longer term.

Just over one third of those undergoing circumcision were tested for HIV and prevalence was 3.4%, compared to 17.1% in the general Luo population, so it sounds like many of those being circumcised are less likely to be infected.

The vast majority, almost 90% of circumcisions, were carried out by the Nyanza Reproductive Health Society (NRHS), which is a bit mysterious as their domain name is currently for sale, but it is said to be an 'NGO'. At least one of the authors of the article on safety is a senior person connected with NRHS (although no competing interests are declared). I met someone who worked for this NGO and he felt that NRHS was very keen to gather and disseminate positive things about VMMC and discouraged employees from finding or alluding to negative aspects.

Given the millions of dollars being spent on what is effectively a vertical health system to carry out medical male circumcision with the aim of reducing HIV transmission from women to men, one would expect high levels of safety, but the operation is not as risk free as some claim. Also, fewer than half of those circumcised ever return for follow-up, which makes one wonder about those living on the streets and those living in slums and in distant areas, for whom returning to the clinic may take up a lot more time and/or money. Also, much of the safety data is collected from clinics that do little other than circumcise men, so safety of circumcisions should reach higher levels than that found in clinics where other health procedures are carried out. But useful comparative figures are not available.

But this poor journalist (and his female friends) has either been deceived by the pre-circumcision sales pitch or he's not very good at doing research. He says his female friends "realise the obvious health benefits, including a lower risk of HIV infection. For women especially, if their boyfriend or husband is circumcised it lessens the chance he will infect them with HIV should he stray outside the relationship." As mentioned above, the stated aim of VMMC is to reduce HIV infection from females to males, nor do the randomized controlled trials show that all HIV transmission was sexual.

The intrepid reporter does point out that even circumcised men are at risk of being infected with HIV, and of infecting others. But he doesn't mention that this campaign doesn't address the problem of already circumcised men thinking they are 'safe'. Nor does it address the problem that many women think circumcision is an indication that a man is less likely to be infected with HIV. On the contrary, not only can circumcised men be infected, but infected men can also be circumcised under the VMMC program. They can be tested and keep their status to themselves, or they can refuse to be tested or to be informed of their status. This could increase the risks that women face unless the program makes the precise implications of mass circumcision clear (although the implications are not clear to anyone yet).

The reporter concludes that his "scar is permanent and hopefully a daily reminder of the cost of faithfulness and real commitment to family, partnership and marriage" (compare his use of the word 'scar' to various definitions of the word 'stigma'). But his circumcision will not bring about his faithfulness and commitment. They are required among circumcised and uncircumcised alike to reduce heterosexual HIV transmission (and useless when it comes to reducing non-sexually transmitted HIV). More poignantly, if he and his wife really are faithful and committed, the circumcision will not give him any additional protection; unless he thinks his wife is not...

Accepting circumcision as a means of reducing the risk of being infected with HIV is also tacitly (or even explicitly) accepting that HIV is almost always transmitted heterosexually. While those remaining uncircumcised may find themselves thereby further stigmatized (they are already stigmatized as Luos and as Africans), those who are circumcised under the VMMC program are reinforcing the view that they and others around them are highly promiscuous, or that they may engage in promiscuous behavior in the future. Those who are circumcised for other reasons may engage in either safe or unsafe sexual behavior, but they will believe that their HIV risk from heterosexual sex is lower than that for uncircumcised men, and that non-sexual risks are not even worth considering.

UNAIDS tries to justify their strenuous efforts to ignore non-sexual HIV risk, especially through unsafe healthcare, by saying that it would confuse people to tell them about more than one risk, and that it may make people more cautious about attending healthcare facilities when they are sick. It is hard to imagine greater confusion that that found among people in non-circumcising populations, and even among circumcising populations. If the aim is to reduce HIV transmission, people must know about all risks, sexual and non-sexual. This will allow them to put a public health intervention such as mass male circumcision in perspective; HIV is not all about sex; therefore VMMC may give little benefit and may do a lot of harm. But hey, it's worth millions!